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Kim C, Mansoor GF, Paya PM, Ludin MH, Ahrar MJ, Mashal MO, Todd CS. Multisector nutrition gains amidst evidence scarcity: scoping review of policies, data and interventions to reduce child stunting in Afghanistan. Health Res Policy Syst 2020; 18:65. [PMID: 32527267 PMCID: PMC7291673 DOI: 10.1186/s12961-020-00569-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 05/05/2020] [Indexed: 12/02/2022] Open
Abstract
Background Child health indicators have substantially improved across the last decade, yet Afghanistan has among the highest child stunting and malnutrition rates in Asia. Multisectoral approaches were recently introduced but evidence for this approach to improve support for and implementation of child nutrition programmes is limited compared to other countries. Methods We reviewed policy and programme data to identify best practices and gaps surrounding child malnutrition in Afghanistan. We conducted a scoping review using broad search categories and approaches, including database and website searches, reference hand-searches, purposive policy and programme document request, and key informant interviews. Inclusion and exclusion criteria were developed iteratively, with abstracts and documents assessed against the final criteria. We abstracted documents systematically and summarised and synthesised content to generate the main findings. Results We included 18 policies and strategies, 45 data sources and reports, and 20 intervention evaluations. Movement towards multisectoral efforts to address malnutrition at the policy level has started; however, integrated nutrition-specific and nutrition-sensitive interventions are not yet uniformly delivered at the community level. Many data sources capturing nutrition, food security and WASH (water, sanitation and hygiene) indicators are available but indicator definitions are not standardised and there are few longitudinal nutrition surveys. Political will to improve household nutrition status has shown increased government and donor investments in nutrition-sensitive and nutrition-specific programmes through combined small- and large-scale interventions between 2004 and 2013; however, evidence for interventions that effectively decrease stunting prevalence is limited. Conclusions This review shows a breadth of nutrition programme, policy and data in Afghanistan. Multisector approaches faced challenges of reaching sufficient coverage as they often included a package of food security, livelihoods and health interventions but were each implemented independently. Further implementation evidence is needed to aid policy and programmes on effective integration of nutrition, food security and WASH in Afghanistan.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.
| | - Ghulam Farooq Mansoor
- FHI 360/Integrated Hygiene, Sanitation, and Nutrition (IHSAN) project, Kabul, Afghanistan
| | - Pir Mohammad Paya
- FHI 360/Integrated Hygiene, Sanitation, and Nutrition (IHSAN) project, Kabul, Afghanistan
| | - Mohammad Homayoun Ludin
- Public Nutrition Directorate, Ministry of Public Health, Islamic Republic of Afghanistan, Kabul, Afghanistan
| | - Mohammad Javed Ahrar
- Rural Water Supply and Irrigation Programme (RuWATSIP) Department, Ministry of Rural Rehabilitation and Development (MRRD), Islamic Republic of Afghanistan, Kabul, Afghanistan
| | - Mohammad Omar Mashal
- FHI 360/Integrated Hygiene, Sanitation, and Nutrition (IHSAN) project, Kabul, Afghanistan
| | - Catherine S Todd
- Division of Reproductive, Maternal, Newborn, and Child Health, Global Health, Population and Nutrition Department, Durham, North, Carolina, United States of America
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Kawaza K, Kinshella MLW, Hiwa T, Njirammadzi J, Banda M, Vidler M, Newberry L, Nyondo-Mipando AL, Dube Q, Molyneux E, Goldfarb DM. Assessing quality of newborn care at district facilities in Malawi. BMC Health Serv Res 2020; 20:227. [PMID: 32183795 PMCID: PMC7079536 DOI: 10.1186/s12913-020-5065-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/02/2020] [Indexed: 11/18/2022] Open
Abstract
Background Malawi is celebrated as one of the few countries in sub-Saharan Africa to meet the Millennium Development Goal of reducing under-5 mortality by two-thirds between 1990 and 2015. However, within this age range neonatal mortality rates are the slowest to decline, even though rates of facility births are increasing. Examining the quality of neonatal care at district-level facilities where most deliveries occur is warranted. Objective The objective of this paper is to evaluate the quality of neonatal care in three district hospitals and one primary health centre in southern Malawi as well as to report the limitations and lessons learned on using the WHO integrated quality of care assessment tool. Methods These facility assessments were part of the “Integrating a neonatal healthcare package for Malawi” project, a part of the Innovating for Maternal and Child Health in Africa (IMCHA) initiative. The WHO integrated quality of care assessment tool was used to assess quality of care and availability and quantity of supplies and resources. The modules on infrastructure, neonatal care and labour and delivery were included. Facility assessments were administered in November 2017 and aspects of care were scored on a Likert scale from one to five (a score of 5 indicating compliance with WHO standards of care; one as lowest indicating inadequate care). Results The continuum of labour, delivery and neonatal care were assessed to identify areas that required improvements to meet standards of care. Critical areas for improvements included infection control (mean score 2.9), equipment, supplies and setup for newborn care in the labor ward (2.3), in the surgical theater (3.3), and nursery (3.4 nursery facilities, 3.0 supplies and equipment), as well as for management of sick newborns (3.2), monitoring and follow-up (3.6). Only one of the 12 domains, laboratory, met the standards of care with only minor improvements needed (4.0). Conclusion The WHO integrated quality of care assessment tool is a validated tool that can shed light on the complex quality of care challenges faced by district-level health facilities. The results reveal that the quality of care needs improvement, particularly for sick and vulnerable newborns.
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Affiliation(s)
- Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi. .,College of Medicine, IMCHA Project, Blantyre, Malawi.
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Tamanda Hiwa
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Jenala Njirammadzi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Mwai Banda
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Laura Newberry
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- College of Medicine, IMCHA Project, Blantyre, Malawi.,Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- College of Medicine, IMCHA Project, Blantyre, Malawi.,Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Elizabeth Molyneux
- College of Medicine, IMCHA Project, Blantyre, Malawi.,Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
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Atiqzai F, Manalai P, Amin SS, Edmond KM, Naziri M, Soroush MS, Sultana S, Yousufi K, van den Akker T, Stekelenburg J, Tappis H. Quality of essential newborn care and neonatal resuscitation at health facilities in Afghanistan: a cross-sectional assessment. BMJ Open 2019; 9:e030496. [PMID: 31473621 PMCID: PMC6720229 DOI: 10.1136/bmjopen-2019-030496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess readiness and quality of essential newborn care and neonatal resuscitation practices in public health facilities in Afghanistan. DESIGN Cross-sectional assessment. SETTING 226 public health facilities in Afghanistan, including 77 public health facilities with at least five births per day (high-volume facilities) and 149 of 1736 public health facilities with fewer than five births per day (low-volume facilities). PARTICIPANTS Managers of 226 public health facilities, 734 skilled birth attendants (SBAs) working at these facilities, and 643 women and their newborns observed during childbirth at 77 high-volume health facilities. OUTCOME MEASURES Availability of knowledgeable SBAs, availability of supplies and compliance with global guidelines for essential newborn care and neonatal resuscitation practices. RESULTS At high-volume facilities, 569/636 (87.9%) of babies were dried immediately after birth, 313/636 (49.2%) were placed in skin-to-skin contact with their mother and 581/636 (89.7%) had their umbilical cord cut with a sterile blade or scissors. A total of 87 newborn resuscitation attempts were observed. Twenty-four of the 87 (27.5%) began to breath or cry after simply clearing the airway or on stimulation. In the remaining 63 (72.5%) cases, a healthcare worker began resuscitation with a bag and mask; however, only 54 (62%) used a correct size of mask and three babies died as their resuscitation with bag and mask was unsuccessful. CONCLUSIONS The study indicates room for improvement of the quality of neonatal resuscitation practices at public health facilities in Afghanistan, requiring only strengthening of the current best practices in newborn care. Certain basic and effective aspects of essential newborn care that can be improved on with little additional resources were also missing, such as skin-to-skin contact of the babies with their mother. Improvement of compliance with the standard newborn care practices must be ensured to reduce preventable newborn mortality and morbidity in Afghanistan.
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Affiliation(s)
| | | | - Sher Shah Amin
- Office of Health and Nutrition, USAID Afghanistan, Kabul, Afghanistan
| | | | | | - Mohammad Samim Soroush
- Reproductive, Maternal, Newborn and Child Health Department, Ministry of Public Health, Kabul, Afghanistan
| | | | | | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen, Groningen, The Netherlands
- Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Hannah Tappis
- Technical Leadership Office, Jhpiego, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bitton A, Fifield J, Ratcliffe H, Karlage A, Wang H, Veillard JH, Schwarz D, Hirschhorn LR. Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. BMJ Glob Health 2019; 4:e001551. [PMID: 31478028 PMCID: PMC6703296 DOI: 10.1136/bmjgh-2019-001551] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/25/2019] [Accepted: 06/15/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed. METHODS Guided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised. RESULTS We retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period. CONCLUSION Our findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.
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Affiliation(s)
- Asaf Bitton
- Ariadne Labs, Boston, Massachusetts, USA
- Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | - Hong Wang
- The Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Jeremy H Veillard
- World Bank Group, Washington, District of Columbia, USA
- Institute of Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Dan Schwarz
- Ariadne Labs, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lisa R Hirschhorn
- Ariadne Labs, Boston, Massachusetts, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Boschi-Pinto C, Labadie G, Dilip TR, Oliphant N, Dalglish SL, Aboubaker S, Agbodjan-Prince OA, Desta T, Habimana P, Butron-Riveros B, Al-Raiby J, Siddeeg K, Kuttumuratova A, Weber M, Mehta R, Raina N, Daelmans B, Diaz T. Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on. BMJ Open 2018; 8:e019079. [PMID: 30061428 PMCID: PMC6067364 DOI: 10.1136/bmjopen-2017-019079] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/28/2017] [Accepted: 05/01/2018] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To assess the extent to which Integrated Management of Childhood Illness (IMCI) has been adopted and scaled up in countries. SETTING The 95 countries that participated in the survey are home to 82% of the global under-five population and account for 95% of the 5.9 million deaths that occurred among children less than 5 years of age in 2015; 93 of them are low-income and middle-income countries (LMICs). METHODS We conducted a cross-sectional self-administered survey. Questionnaires and data analysis focused on (1) giving a general overview of current organisation and financing of IMCI at country level, (2) describing implementation of IMCI's three original components and (3) reporting on innovations, barriers and opportunities for expanding access to care for children. A single data file was created using all information collected. Analysis was performed using STATA V.11. PARTICIPANTS In-country teams consisting of representatives of the ministry of health and country offices of WHO and Unicef. RESULTS Eighty-one per cent of countries reported that IMCI implementation encompassed all three components. Almost half (46%; 44 countries) reported implementation in 90% or more districts as well as all three components in place (full implementation). These full-implementer countries were 3.6 (95% CI 1.5 to 8.9) times more likely to achieve Millennium Development Goal 4 than other (not full implementer) countries. Despite these high reported implementation rates, the strategy is not reaching the children who need it most, as implementation is lowest in high mortality countries (39%; 7/18). CONCLUSION This survey provides a unique opportunity to better understand how implementation of IMCI has evolved in the 20 years since its inception. Results can be used to assist in formulating strategies, policies and activities to support improvements in the health and survival of children and to help achieve the health-related, post-2015 Sustainable Development Goals.
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Affiliation(s)
- Cynthia Boschi-Pinto
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
- Instituto de Saúde Coletiva, Universidade Federal Fluminense, Niteroi, Brazil
| | - Guilhem Labadie
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
| | | | - Nicholas Oliphant
- The Global Fund to Fight AIDS, Geneva, Switzerland
- UNICEF, New York, USA
| | - Sarah L Dalglish
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
| | - Samira Aboubaker
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
| | | | - Teshome Desta
- World Health Organization, Regional Office for East and Southern Africa, Harare, Zimbabwe
| | - Phanuel Habimana
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | | | - Jamela Al-Raiby
- World Health Organization, Regional Office for Eastern Mediterranean, Cairo, Egypt
| | - Khalid Siddeeg
- World Health Organization, Regional Office for Eastern Mediterranean, Cairo, Egypt
| | | | - Martin Weber
- World Health Organization, Regional Office for Europe, Copenhagen, Denmark
| | - Rajesh Mehta
- World Health Organization, Regional Office for South-East Asia, New Delhi, India
| | - Neena Raina
- World Health Organization, Regional Office for South-East Asia, New Delhi, India
| | - Bernadette Daelmans
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
| | - Theresa Diaz
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
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Liberati EG, Peerally MF, Dixon-Woods M. Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare. Int J Qual Health Care 2018; 30:39-43. [PMID: 29300992 PMCID: PMC5890869 DOI: 10.1093/intqhc/mzx163] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 09/22/2017] [Accepted: 11/21/2017] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Though healthcare is often exhorted to learn from 'high-reliability' industries, adopting tools and techniques from those sectors may not be straightforward. We sought to examine the hierarchies of risk controls approach, used in high-risk industries to rank interventions according to supposed effectiveness in reducing risk, and widely advocated as appropriate for healthcare. DESIGN Classification of risk controls proposed by clinical teams following proactive detection of hazards in their clinical systems. Classification was based on a widely used hierarchy of controls developed by the US National Institute for Occupational Safety and Health (NIOSH). SETTING AND PARTICIPANTS A range of clinical settings in four English NHS hospitals. RESULTS The four clinical teams in our study planned a total of 42 risk controls aimed at addressing safety hazards. Most (n = 35) could be classed as administrative controls, thus qualifying among the weakest type of interventions according to the HoC approach. Six risk controls qualified as 'engineering' controls, i.e. the intermediate level of the hierarchy. Only risk control qualified as 'substitution', classified as the strongest type of intervention by the HoC. CONCLUSIONS Many risk controls introduced by clinical teams may cluster towards the apparently weaker end of an established hierarchy of controls. Less clear is whether the HoC approach as currently formulated is useful for the specifics of healthcare. Valuable opportunities for safety improvement may be lost if inappropriate hierarchical models are used to guide the selection of patient safety improvement interventions. Though learning from other industries may be useful, caution is needed.
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Affiliation(s)
- Elisa G Liberati
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge CB2 OAH, UK
| | - Mohammad Farhad Peerally
- Department of Health Sciences, Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, University of Leicester, Leicester, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge CB2 OAH, UK
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Krüger C, Heinzel-Gutenbrunner M, Ali M. Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys. BMC Health Serv Res 2017; 17:822. [PMID: 29237494 PMCID: PMC5729502 DOI: 10.1186/s12913-017-2781-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/06/2017] [Indexed: 01/29/2023] Open
Abstract
Background Integrated Management of Childhood Illness (IMCI) is regarded as a standard public health approach to lowering child mortality in developing countries. However, little is known about how health workers adhere to the guidelines at the national level in sub-Saharan African countries. Methods Data from the Service Provision Assessment surveys of Namibia (NA) (survey year: 2009), Kenya (KE) (2010), Tanzania (TZ) (2006) and Uganda (UG) (2007) were analysed for adherence to the IMCI guidelines by health workers. Potential influencing factors included the survey country, patient’s age, the different levels of the national health system, the training level of the health care provider (physician, non-physician clinician, nurse-midwife, auxiliary staff), and the status of re-training in IMCI. Results In total, 6856 children (NA: 1495; KE: 1890; TZ: 2469; UG: 1002 / male 51.2–53.5%) aged 2–73 months (2–24 months, 65.3%; median NA: 19 months; KE: 18 months; TZ: 16 months; UG: 15 months) were clinically assessed by 2006 health workers during the surveys. Less than 33% of the workers carried out assessment of all three IMCI danger signs, namely inability to eat/drink, vomiting everything, and febrile convulsions (NA: 11%; KE: 11%; TZ: 14%; UG: 31%) while the rate for assessing all three of the IMCI main symptoms of cough/difficult breathing, diarrhoea, and fever was < 60% (NA: 48%; KE: 34%; TZ: 50%; UG: 57%). Physical examination rates for fever (temperature) (NA: 97%; KE: 87%; TZ: 73%; UG: 90%), pneumonia (respiration rate/auscultation) (NA: 43%; KE: 24%; TZ: 25%; UG: 20%) and diarrhoea (dehydration status) (NA: 29%; KE: 19%; TZ: 20%; UG: 39%) varied widely and were highest when assessing children with the actual diagnosis of pneumonia and diarrhoea. Adherence rates tended to be higher in children ≤ 24 months, at hospitals, among higher-qualified staff (physician/non-physician clinician) and among those with recent IMCI re-training. Conclusion Despite nationwide training in IMCI the adherence rates for assessment and physical examination remained low in all four countries. IMCI training should continue to be provided to all health staff, particularly nurses, midwives, and auxiliary staff, with periodic re-training and an emphasis to equally target children of all age groups.
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Affiliation(s)
- Carsten Krüger
- Department of Paediatrics, Witten/Herdecke University, Witten, Germany. .,Children's Hospital, St. Franziskus Hospital, Robert-Koch-Strasse 55, D-59227, Ahlen, Germany.
| | | | - Mohammed Ali
- Faculty of Health Sciences, School of Nursing, Midwifery & Paramedicine, Curtin University, Perth, Australia
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